Clinical Guideline for the Management of Skin Toxicity associated with ...

Clinical Guideline for the Management of Skin Toxicity associated with Systemic Anti-Cancer Therapy (SACT) in Adult

Patients

Lead Author:-

Millie Galvin Specialist Oncology Pharmacist NHS Grampian

Regional Document Number:NOS-STG-006

Reviewed by:Judith Jordan Regional Lead Pharmacist (on behalf of North SACT Delivery Group - NSDG)

Approval date:October 2018

Approved by:-

Ian Rudd Director of Pharmacy NHS Highland

(on behalf of North SACT Governance Group - NSGG)

Review date:October 2020

Uncontrolled When Printed Version 1

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Contents

Page

1. Outline of procedure............................................................................... 3 2. Area of application................................................................................. 3 3. Introduction........................................................................................... 3 4. General skin care advice..................................................................... 3 - 4 5. Assessment and Management:-

5.1 Initial assessment........................................................................ 5 5.2 General management of patients admitted with skin rash thought to be

due to SACT.................................................................................5 6. General skin rash toxicity grading...............................................................6 7. Palmar-plantar erythrodysaesthesia (PPE) or hand-foot syndrome (HFS)...........7 8. Epidermal Growth Factor Receptor Inhibitors................................................8 8.1 Acneiform rash.................................................................................8 - 10 8.2 Hair changes ...................................................................................... 11 8.3 Pruritis .............................................................................................. 11 8.4 Nail changes ? paronychia..................................................................11-12 8.5 Finger and heel fissures.........................................................................13 9. References..........................................................................................14

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1. Outline of Procedure This document covers the prevention and treatment of skin toxicity associated with systemic anti-cancer therapy in adult patients. Please refer to other appropriate guidelines for paediatric patients or skin toxicity related to other causes for example radiotherapy. Management of skin toxicity due to immunotherapy treatments is detailed in the North Guideline for Management of Immunotherapy Toxicity and is not covered in this document.

2. Area of Application This guideline applies to all adult SACT services across the North region, except for the administrative areas of Argyll and Bute in NHS Highland which is linked to the WOSCAN CEL (2012) 30 governance framework.

3. Introduction This document gives advice on the management of common skin toxicities related to SACT. SACT may cause other dermatological conditions (skin toxicities) which are not covered in this document and where necessary advice should be sought from a dermatologist. Dermatological conditions may occur due to the underlying cancer, other medical conditions and medications and therefore alternative causes should always be considered.

4. General Skin Care Advice Patients prescribed SACT should have regular review for toxicities as outlined in the relevant tumour specific Clinical Management Guidelines (available on the NCA website) or within relevant local SACT protocols. The general advice detailed below in Table 1 is applicable to any patient prescribed SACT. Advise patients to contact their doctor / treatment nurse or the Cancer Treatment Helpline number if there are any significant changes to their skin that they are concerned about during treatment. Encourage them that early reporting should enable timely intervention.

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Table 1: General Skin Care Advice

BODY

Recommend good fluid intake. Avoid wearing tight clothes. Use lukewarm water to bathe and avoid long periods in the bath or shower Avoid soap, use perfume free soap substitute products e.g.BP emulsifying

ointment or Zerobase? cream. Use regular emollients ideally 2 -3 times per day, apply in the direction of hair

growth to reduce the risk of folliculitis. Avoid alcohol based or irritant antibacterial skin products, use oils rather than

gels. Dry skin gently with a soft towel by patting the skin. Use hypoallergenic make up products. Consider using non-biological washing detergents. If shaving is required, use an electric razor. Do not scratch itchy skin. Avoid sun exposure and cover sun exposed areas with light clothing. If sun

exposure cannot be avoided, then a sunscreen of at least SPF30 with protection against UVA and UVB must be applied 30 minutes pre-exposure.

HAIR Use mild shampoo for washing hair e.g. baby shampoo. Avoid using hairdryers, straighteners or hot rollers. Avoid permanent colouring or perming.

HANDS AND FEET Keep nails clean and trimmed. Avoid pushing back cuticles or tearing the skin around the nail. Ensure to dry between the toes after bathing. Wear loose fitting shoes to avoid pressure on the nail. Avoid Shellac? or gel nail polish. Wear gloves when washing dishes or using chemical agents. Vaseline? around the nail beds can act as a barrier.

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5.1 Initial Assessment

All patients presenting with rash should be reviewed face to face as skin toxicities are difficult to assess over the phone. It is important to make a diagnosis of, and treat appropriately, skin rash unrelated to SACT for example shingles, cellulitis, exacerbation of underlying skin condition.

Patients receiving SACT are at risk of neutropenic sepsis, check temperature if neutropenic sepsis suspected and manage as per local guidelines.

Ascertain which SACT regimen the patient is on and the date of last treatment. If the patient has received treatment with which skin rash is commonly associated e.g. EGFR inhibitor, capecitabine, then refer to the specific section of this document.

Check if the patient has had recent radiotherapy, or stem cell or bone marrow transplant.

Check if the patient has recently started any medication and assess if a drug reaction is likely.

Check if there is a history of skin complaints. Assess the rash. Document the site, appearance, whether it is localised or

widespread, flat or raised and the presence or absence of any pustules, ulcers, peeling, fluid filled vesicles or bleeding. Check if the rash is itchy. Consider liver/kidney problems, dry skin or allergy. Check the general health of the patient and if there are any signs of infection. Ask if the patient has been in recent contact with shingles or chicken pox.

5.2 General Management of Patients admitted with skin rash thought to be due to SACT

Ensure general care measures as per Table 1.

Initial Management

Assessment of fluid balance status, establish IV access if any signs of dehydration or sepsis

Intravenous fluids according to fluid balance status and renal function Swab any open areas for infection and send to microbiology Treat any infected lesions as appropriate and adjust antibiotics according to clinical

condition, myelosuppression, swab results and local antibiotic guidelines. Check platelet count as rash may be secondary to thrombocytopenia Interrupt SACT treatment and discuss with medical team

Ongoing Management

Reassess daily (close monitoring of routine observations as at risk of infection) Observe for development of neutropenic sepsis, neutropenia or other SACT toxicities Fluid balance and/or daily weights Dermatology review if concerns / uncertainty of diagnosis

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